Healthcare Provider Details

I. General information

NPI: 1073660007
Provider Name (Legal Business Name): DR. WILLIAM BRELL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 E SUNSHINE ST STE E10
SPRINGFIELD MO
65804-1237
US

IV. Provider business mailing address

1531 E SUNSHINE ST STE E10
SPRINGFIELD MO
65804-1237
US

V. Phone/Fax

Practice location:
  • Phone: 417-883-5866
  • Fax: 417-883-5898
Mailing address:
  • Phone: 417-883-5866
  • Fax: 417-883-5898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number010483
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: